Rackling against the breast bone

When I was a kid, I liked to do drugs as much as the next trailer trash, but I never, never understood how someone could stick a needle in their arm–until I had my wisdom teeth out. (Trailer trash explained in the English notes below.) The oral surgeon pushed the plunger on the syringe, I watched the medication travel down the IV line, and before I slipped off into unconsciousness, I heard the sound of the wind blowing in my ears and thought Ohhhhhhhh–THIS is why they do it.

I was lucky–before anesthesia was invented in the mid-19th century, that would’ve been a horrible procedure. Here’s a woman’s description of her mastectomy in 1811. Her name is Fanny Burney, and her record of the operation has survived until today because she was both a popular novelist and a part of the court of George III. This extract from a letter to her big sister Esther is quite unusual, in that it is a rare record of pre-anesthesia surgery from the patient’s point of view, rather than from the surgeon’s point of view, which is much better documented. Just in case you don’t feel up to reading the whole dreadful thing, I’ve shortened it, and then I’ve bolded the most horrific sentence—the sentence that people cite the most.  You’ll find the whole thing at the bottom of the post, after the English notes.

…when the dreadful steel was plunged into the breast—cutting through veins—arteries—flesh—nerves… I began a scream that lasted unintermittingly during the whole time of the incision—and I almost marvel that it rings not in my Ears still! so excruciating was the agony. When the wound was made, and the instrument was withdrawn, the pain seemed undiminished, for the air that suddenly rushed into those delicate parts felt like a mass of minute but sharp and forked poniards, that were tearing the edges of the wound—but when again I felt the instrument—describing a curve—cutting against the grain, if I may so say, while the flesh resisted in a manner so forcible as to oppose and tire the hand of the operator, who was forced to change from the right to the left—then, indeed, I thought I must have expired… The instrument this second time withdrawn, I concluded the operation over—Oh no! —Dr Larry rested but his own hand, and—Oh Heaven!—I then felt the Knife rackling against the breast bone—scraping it!—This performed, while I yet remained in utterly speechless torture…

Once a year I spend a week in Guatemala with a group of physicians, nurses, operating room techs, and therapists who do free surgeries for people for whom the almost-free national health care system is still too expensive.  When people think about groups like ours, they mostly think about the surgeons, and the stories that people want to hear are mostly about the surgeries that those surgeons do—the children who will be able to get married some day because a plastic surgeon repaired their cleft lip; the child who will be able to learn to write because the hand surgeon gave him functioning fingers; the woman who will be able to go to the market and sell corn again—thereby getting cash to pay for her kids’ school supplies—because the gynecological surgeons repaired her prolapsed uterus and urinary incontinence. There’s someone who usually gets left out of these stories, though–the anesthesiologists and nurse anesthetists who made it possible for those surgeries to happen.

Reasonable people could debate about what the most important inventions in the history of humankind have been. The wheel makes most lists; penicillin gets on a lot of them; stupid ones have “The Internet.” Here’s my hypothesis, in no particular order:

  1. The toothbrush
  2. Vaccines
  3. Corrective lenses
  4. Anesthesia

After that, the importance levels drop off pretty quickly–vaccines have killed some diseases forever (and may kill more if bad hombres with political motivations don’t prevent it–Boko Haram, Trump administration Cabinet member Ben Carson, and occasional presidential candidate Jill Stein come to mind here). Penicillin, on the other hand, is a once-great idea whose time will soon be past, leaving us with no good answers for XDR (extensively drug-resistant) tuberculosis or for people like my former Navy shipmate whose penchant for returning from port visits with gonococcal pharyngitis was legendary throughout the 6th Fleet. Few things will ever be as near and dear to our hearts as our toothbrushes, but the Internet will die as soon as the zombie apocalypse starts, leaving us poorer in idiotic Twitter feeds (see death of Internet) but immeasurably richer in our appreciation for the value of our ties to our fellow humans (see zombie apocalypse).

Anesthesia, though: let’s think about some things that would not have ever happened without anesthesia. Bear in mind that before anesthesia as we know it today was invented in the 1840s or so, surgery was something to be avoided at all costs and, in the case of non-emergencies like cancer, until the last possible minute; if unavoidable, it was to be done as quickly as possible. (The main criterion for the quality of an amputation, other than the patient surviving it, was how quickly it was done; as far as I know, amputation was the main surgical intervention of the American Civil War.) With anesthesia, though–with anesthesia, surgeons could be careful. They could do things that took time; they could do things that were complicated. As Dr. David Metro, our chief anesthesiologist, put it to me: “anesthesia is what has made every surgical advance since the mid-19th century possible. Organ transplantation–it saved over 33,000 lives last year–cochlear implants, cataract surgery, hip replacements, coronary artery bypass surgery–all of that is only possible because we can put patients to sleep, keep them there painlessly for as long as necessary, and then wake them up again afterwards.”

That’s what anesthesia has done for us–but, on some level, anesthesia is just a bunch of chemicals. You could give them to yourself, like folks once used ether for fun. (See John Irving’s novel The cider house rules for where playing with ether can lead–it’s nowhere good.)  But, anesthesiologists–they’re another thing altogether. I’m not talking here about their technical skills–about the nurse anesthetist who worked the night shift in a hospital where I worked in the late 1980s, and who saved the life of pretty much every single patient whose life got saved in our emergency room, or about the anesthesiology resident who picked up on a case of tuberculosis a couple years ago here in Guatemala. I’m talking about a display of honesty and intellectual rigor that has had effects not just in the surgical world, but in the engineering world in general and in flight safety in particular.

In the 1970s, four anesthesiologists at Massachusetts General Hospital undertook a study of errors by members of their profession. 47 of their colleagues discussed with them–on tape–the errors that they had made in their careers. They talked about 359 incidents in total, of which 82% were caused by human error. As one commentator on that paper put it, Anesthesiology is the one domain in which patient safety was identified as a problem long before the Institute of Medicine’s 1999 wake up call to the healthcare community. Not only was the problem identified in the late 1970s, but anesthesiologists faced the issues, taking actions to effect changes that would reduce errors, adverse outcomes, and injuries. While it is often difficult to trace the historical path of change, there is reason to believe that the anesthesia critical incident studies planted seeds of ideas for others, either directly or subliminally.

Along with later work on equipment problems in anesthesia that proceeded on the same methodology, this body of research set the standard for a broad field of research in engineering on how to understand problems with systems, and how to use your understanding of those problems to make those systems safer. Table 3 in that paper gives nice insight into how that works. It shows the distribution of frequent types of equipment-related errors; one thing that you notice there is how many of the frequent categories of problems are related to misconnections or disconnections of the various and sundry tubing systems involved. One of the responses to this finding was to make it mandatory to have connectors on medical gas systems that cannot be plugged into the wrong gas supply–today, it is mechanically impossible to plug your oxygen line into a “room air” supply, or your room air supply into a vacuum. Today’s anesthesia machines are one of the best-designed kinds of systems for supporting a human life on this planet, and the anesthesiologist’s approach to thinking about what he or she does is ubiquitous in fields as diverse as flight safety—and surgery. As Atul Gawande put it in his book The checklist manifesto, describing the ways that checklists are used to help a pilot and co-pilot work together to recover from a potentially fatal emergency: as integral to a successful flight as anesthesiologists are to a successful operation.  Step back for a second and think about where these advances came from: anesthesiologists admitting to other people what they did wrong, on the record.  I wish that I had that kind of courage.

Connectors for the hoses for four different kinds of gases.  It’s not physically possible to plug these hoses into the wrong source–a product of those studies by anesthesiologists.

I woke up when my surgery ended, poorer by four molars but with an increased appreciation for what anesthesia and anesthesiologists bring to the world.  When our patients wake up here in Guatemala, it’s usually with their lives changed–Monday’s reconstruction of a hand for a teenager who I’ve seen every one of the five years that I’ve been coming here, as it’s a complicated surgery that has to be done in stages; yesterday’s removal of a mass on the right wrist of a woman whose job involves writing with a pen all day, and who therefore was losing the ability to support herself in a country in which there is no such thing as unemployment insurance, or disability support for people who can’t work; Tuesday’s repair of a cleft lip for a kid who otherwise would have been unlikely to find a spouse, in a country in which your only social support net is your family…

Enjoying these posts from Guatemala?  Why not make a small donation to Surgicorps International, the group with which I come here?  You wouldn’t believe how much aspirin we can hand out for the cost of a large meal at McDonalds–click here to donate.  Us volunteers pay our own way–all of your donations go to covering the cost of surgical supplies, housing for patients’ families while their loved one is in the hospital, medications, and the like.

English notes

Trailer trash: Here’s Wikipedia’s definition of this very American term: Trailer trash (or trailer park trash) is a derogatory North American English term for poor people living in a trailer or a mobile home.[1][2] It is particularly used to denigrate white people living in such circumstances[3] and can be considered to fall within the category of racial slurs.[4] The term has increasingly replaced “white trash” in public and television usage.

How I used it in the post: When I was a kid, I liked to do drugs as much as the next trailer trash, but I never, never understood how someone could stick a needle in their arm–until I had my wisdom teeth out.

The full description of Fanny Burney’s surgery

Here are the two paragraphs of Fanny Burney’s letter to her sister describing her surgery.  There’s more to the letter, which also describes the whole process of the development and diagnosis of her breast cancer–there’s a link to it at the end of the post.

My dearest Esther,—and all my dears to whom she communicates this doleful ditty, will rejoice to hear that this resolution once taken, was firmly adhered to, in defiance of a terror that surpasses all description, and the most torturing pain. Yet—when the dreadful steel was plunged into the breast—cutting through veins—arteries—flesh—nerves—I needed no injunctions not to restrain my cries. I began a scream that lasted unintermittingly during the whole time of the incision—and I almost marvel that it rings not in my Ears still! so excruciating was the agony. When the wound was made, and the instrument was withdrawn, the pain seemed undiminished, for the air that suddenly rushed into those delicate parts felt like a mass of minute but sharp and forked poniards, that were tearing the edges of the wound—but when again I felt the instrument—describing a curve—cutting against the grain, if I may so say, while the flesh resisted in a manner so forcible as to oppose and tire the hand of the operator, who was forced to change from the right to the left—then, indeed, I thought I must have expired.

I attempted no more to open my Eyes,—they felt as if hermetically shut, and so firmly closed, that the Eyelids seemed indented into the Cheeks. The instrument this second time withdrawn, I concluded the operation over—Oh no! presently the terrible cutting was renewed—and worse than ever, to separate the bottom, the foundation of this dreadful gland from the parts to which it adhered—Again all description would be baffled—yet again all was not over,—Dr Larry rested but his own hand, and—Oh Heaven!—I then felt the Knife rackling against the breast bone—scraping it!—This performed, while I yet remained in utterly speechless torture, I heard the Voice of Mr Larry,—(all others guarded a dead silence) in a tone nearly tragic, desire everyone present to pronounce if anything more remained to be done; The general voice was Yes,—but the finger of Mr Dubois—which I literally felt elevated over the wound, though I saw nothing, and though he touched nothing, so indescribably sensitive was the spot—pointed to some further requisition—and again began the scraping!—and, after this, Dr Moreau thought he discerned a peccant attom (fragments of diseased [peccant] breast tissue)—and still, and still, M. Dubois demanded attom after attom.

Web site with Fanny Burney’s letter http://newjacksonianblog.blogspot.com/2010/12/breast-cancer-in-1811-fanny-burneys.html

Blog about pre-anesthesia surgery https://thechirurgeonsapprentice.com/2014/07/16/the-horrors-of-pre-anaesthetic-surgery/


A letter to my colleagues

Dear colleagues,

It is well known that there are certain things that one doesn’t talk about in professional contexts, and since social media has pretty much become a professional context for many of us, that includes Facebook, Twitter, and the like.  One of the foremost of those things about which one is taught not to talk is politics.  Nevertheless: as some of you may have noticed—and as I hope that all of you will notice as you read this message—since the results of the last presidential election in the United States, I have not been quiet in my publicly visible postings on Facebook, Twitter, or this blog about my position regarding Trump.  I will state that position briefly here: I am opposed to him.  When I say “him,” I am referring to the policies that he has espoused; to the actions that he has taken; to his dishonesty; to his tolerance of white supremacists; to his attacks on the judiciary and the press; to his actions towards women, specific ethnic groups, and most of all, his actions against Muslims.  This list is not meant to be exhaustive—I mention here only the things that have gotten the most public attention.

As I pointed out above, talking about politics in a professional setting is something that we are taught not to do—in most of our cases, from the beginning of our careers.  There is a reason for this: one does not want to alienate colleagues in an intellectual context over issues that don’t relate directly to one’s position on professionally relevant topic.  Consequently, my twofold purpose in writing this message to you will probably strike you as counter-intuitive, and therefore, I’d like to explain it to you, my colleagues—and to persuade you to act on it.

My first purpose in writing this letter is to make my position known, as widely as possible, and specifically, as widely as possible within my professional world.  My second purpose is to encourage my professional colleagues to do the same.  I’ll argue that making my position known is a responsibility, and a moral responsibility at that; then I’ll present data that suggests that specifically in your position as a scientist, you have a responsibility here as well; a responsibility, and a stake, and a unique platform from which you have the capacity to act—or not.

As a scientist, you like data—so, I’ll give you some.  In the late 19th and early 20th centuries, Germany was one of the scientific powerhouses of the world.  Even after a boycott of German scientists in the post-WWI period, German science—and German-language scientific publishing—continued to be dominant in some fields (chemistry in particular), and strong in many others.

On April 7th, 1933, the Reichstag passed the Law for the Restoration of the Professional Civil Service.  It made three categories of people ineligible for employment in academia: (1) non-Aryans, (2) members of the Socialist and Communist parties, and (3) political appointees of the preceding (non-Nazi) government.  According to Michael Gordin’s excellent Scientific Babel: How science was done before and after global English, as many as 25% of all German physicists were let go; “at certain centers, most prominently Göttingen, almost the entire department of physics and mathematics was gutted…about one in five, or 20%, of scientists had been driven from their jobs by 1935, followed by another wave when Austria was annexed in 1938…” Travel into and out of Germany became difficult, and to some extent less desirable, since many of the best scientists could no longer be worked with, whether because they had fled Germany or because they no longer had academic posts.

The consequences for German science were pretty devastating.  As Gordin tells it:

…the most immediate and perhaps the one with the longest-lasting consequences [was] the rupture of the graduate student and postdoctoral exchange networks….One of the most salient indications of the importance of German science [before the war] was the centrality of German universities as the destination of choice for foreign students….

What happened next?  Gordin again:

These networks [of collaboration and exchange of graduate students and post-doctoral fellows] did not reassemble until after the war, and they reassembled with the United States as the hub.

We have responsibilities here.  They are of three kinds: our responsibilities as human beings, as Americans, and as scientists.  Our responsibilities as human beings have been discussed extensively by far better writers than me since pretty much as soon as the ashes of WWII started cooling, and I will take them as a given.  Our responsibilities as Americans are related to Trump’s profoundly un-American actions; I have written about those, from my specific perspective as a veteran of the American armed forces, elsewhere (https://goo.gl/XvmuV7).  Instead, I will emphasize here your responsibilities as a scientist.  Your responsibilities as a scientist are of two kinds: your responsibility towards others in your capacity as a scientist, and your responsibility towards science itself.

As the philosopher Alan Chalmers has pointed out, we lay claim to science, and to being a scientist, for a reason: being a scientist confers a certain kind of credibility that people who do things similar to science do not have.  That means that you can speak out against Trump from a position that is founded on data and supported by logic; that at least tries (hopefully better than this letter) to eschew emotion in favor of evidence and reason; that takes advantage of the intellectual capital that our predecessors have been building up for us since Aristotle.  You can speak out over beers with your colleagues.  And, yes: you can speak out in your classrooms—all that it takes is not avoiding the many times that the actions of the current administration are relevant to questions of ethics, of the role of science in society—and its suppression with respect to topics like climate change and vaccinations.  (For those of us who work on language processing and social media data, it’s difficult NOT to talk about Trump.)  You can speak out in your faculty meetings.  Are you skeptical about this?  I suggest to you this thought experiment: pick your favorite social-political horror of the past century, and ask yourself this: would scientists, professors, government employees have been justified in speaking out against it in their professional capacities?  I think that you’ll arrive at a “yes” on this.

Those responsibilities towards other people, as a scientist, are the most important.  But, you have another responsibility, too: toward science.  I began my argumentation in this letter with data on what happened to German science in and after 1933.  The time is ripe for the same thing to happen to American science today—and while American science does not constitute the entirety of science, it constitutes a hell of a lot of it.  There’s some sense in which protecting science is everyone’s duty.  But, not everyone is really qualified to do so.  You, however, are.  And if you want to do that, the most effective way to do it is not to argue with your friends about the causal factors involved in climate change (although I certainly don’t want to discourage you from doing so)—the most effective way to do this is by getting at the root of the problem.  Speak out about Trump and his administration, and do it as a professional.

There is a potential counter-argument to my point in this letter.  It is commonly held that science should not be politicized.  Certainly we can point to cases in which the overt politicization of science has had bad consequences both for science, and for society—consider the effects of Lysenko on Soviet biology, and Nicholas Marr’s on linguistics.  (Lysenko is probably familiar to most of my colleagues, but Marr less so.  You can find a marvelous discussion of his work, of how Stalin used it to justify Russification, and of the consequences that it had for non-Russian speakers in Marina Yaguello’s book, whose unfortunately poorly titled translation was published in English as “Lunatic lovers of language.”)

To this potential counter-argument, I respond: it’s too late—science has already been politicized.  Science has been getting politicized in the US since at least 1975 and the Proxmire Golden Fleece Awards.  (I’ll point out here that Proxmire was a Democrat, not a Republican.)  Khan et al. describe politically-motivated attempts to stop vaccination in Nigeria and in Pakistan.   In 2016, three major candidates for the Republican nomination (Trump, Cruz, and Rubio) all used environmental science as a target.  Science has been politicized—by the bad guys.  Staying out of the fight over science means letting those bad guys win.

There’s an implicit assumption in my encouraging you to speak up about your take on the current situation: an assumption that you share my position.  I actually do, in fact, assume that. I also assume that there is some small number of my colleagues that are Trump supporters—it doesn’t seem very probable that a scientist would support Trump, but variability is a fact of being human, and it’s certainly possible.  If that describes you: I do want you to express your opinion, and I will guarantee you one thing, and ask the corresponding of you.  I guarantee you that I will listen respectfully to what you have to say, and that I will think about it before I respond.  I will then ask you to do the same—to listen to what I have to say, and to think about it before you respond.  I encourage this precisely because I am a scientist: being a scientist (or at least being a good one) requires being open to the possibility that you are wrong, and if you are, in fact, wrong, wanting to find out about it sooner rather than later.  I would be pretty surprised if you, as a scientist, didn’t come to see things my way, and I’m pretty sure that if you didn’t, it would not be because of the facts or your inability to interpret them, but rather because of a failure on my part to present them cogently.  But: as a scientist, I remain open to the possibility that I’m wrong, and if you disagree with me on things Trumpian, I will listen to you—respectfully, and giving due consideration to your reasoning.

I’m writing you this letter with the purpose of speaking out, as loudly and as clearly as I can; and I’m writing you this letter to ask that you do the same.  If my appeal to your conscience is not enough to convince you: let me appeal to your grandchildren.  Personally, I have enormous faith in America’s ability to right itself; we have never, ever been a perfect country, but we have always striven to improve our country.  Someday, we will end the current surreal situation.  What happens then?  As Jonathan Safran Foer put it in his novel Everything is illuminated (incidentally the most compelling illustration of the importance of collocations and of statistical language modelling that I’ve ever seen), in Europe the question that everyone asks themselves today is: what did Grandpa do during the war?  Someday your grandchildren will ask what you did during the Trump administration.  You can choose for the answer to be “I kept my head down and hoped that they wouldn’t come for me;” you can choose for the answer to be “I figured out what I could do, and I did it.”


Kevin Bretonnel Cohen

Khan et al. on vaccination: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4635542/


Remember: the only way that people will expect you to know everything is if you pretend that you do.

Once a year I spend a week in Antigua, Guatemala, with a group that does free surgeries for people for whom even the almost-free national health care system is too expensive.  My part is to do Spanish-English interpreting.  You can read about some of the mechanics of a surgical mission at this link.  To give you a feel for what the interpreting part of it is like, here is the introduction to a manual for our interpreters.


Congratulations on being selected as an interpreter for Surgicorps!  If you went through the work of applying to go on a mission, I don’t have to convince you what a rewarding experience this will be. As Dr. David Kim, our medical director, put it: “Interpreters play an integral part in the Surgicorps mission, assuring nervous patients and their families—at a very frightening point in their lives—that they will be heard and understood if they are in pain, and that they will be able to understand pre- and post-operative instructions—it is a big comfort to them.”

The purpose of this manual is not to teach you medical Spanish.  Rather, its purpose is to give you some suggestions about how to prepare for your Surgicorps mission.  The manual will cover some aspects of medical interpretation in general, medical interpretation for Surgicorps in Guatemala in particular, and some of the vocabulary that is specific to the hospital in which we operate that you are likely to need.  In addition, some Central American Spanish grammar and vocabulary will be discussed, as well as general advice on how to comport yourself in a surgical setting.

If you’re not insanely hubris-ridden, you are already starting to worry about whether or not you are up to the task.  You can more productively spend your time preparing, rather than worrying, and the more prepared you are, the less anxious you get to feel when you arrive in Guatemala.

What to expect when you’re expecting a mission in Guatemala

Where expectations are concerned, the most important thing to be aware of is not your expectations, but the practitioners’ expectations of you.  The practitioners will expect you to be proficient in Spanish, but they will not expect you to be proficient in medical Spanish.  You are probably not proficient in medical English, and you will not be expected to be proficient in medical Spanish, either.  You should, however, be quite familiar with anatomical terms.  This book will cover some medical vocabulary in Spanish; it will be much easier for you to learn it if you know what it means in English, and you should consult a good book on English medical terminology if you are not familiar with it.  .  Remember, though: the only way that the practitioners will expect you to be familiar with medical vocabulary is if you pretend that you are.

An important expectation is that you will be honest and forthcoming when you are not sure what is being said.  This applies equally if you are not sure how to interpret what a patient is saying to the practitioner, and if you are not sure how to interpret what the practitioner is saying to the patient.  I guarantee you that the practitioners will trust and respect you more if they know that you will make clear when you do not understand, and will ask for clarification, than if they think that you are trying to bluff your way through something.

General advice for behavior in the hospital

There are a number of principles that should guide your behavior in the hospital.  The ones that are listed here come from general principles for safe and ethical behavior in health care settings, as well as experience on Surgicorps missions.  I’ll list them briefly here, and then expand on them below:

  • Do not run, ever.
  • Be familiar with principles of confidentiality.  Think hard before you post something about the mission on social media.
  • Be familiar with proper dress and behavior in the operating suite and associated spaces.  (The OR staff will help you with this.)
  • Be familiar with proper dress and behavior around sterile fields.  (See above about the OR staff.)
  • In case of doubt, follow the most recent instruction.
  • Develop a highly refined sense of smell.
  • Know your limits in interpretation situations.\item Know your limits in clinical situations.
  • Never answer a patient’s or family member’s question with anything other than some version of “I’m not a doctor, I don’t know—I’ll go find out.”
  • Clarify, clarify, clarify.
  • Nothing is ever about you.  Everything is always about the patient.

Do not run, ever

If you’re a health care professional, the first thing that you learn is probably not first aid, but rather this: never run in a hospital.  It just freaks everyone out and creates a commotion that will probably hurt the situation more than it will help it.  Plus, if you trip, go flying headlong, and crack your head open, you are not going to be any help whatsoever, and your coworkers are now going to have two patients in crisis, not just one.  In case of emergency: just walk quickly.

In case of doubt, follow the most recent instruction

In the unlikely event of a serious situation where your help is needed, sometimes someone will tell you to do one thing, and then someone else will tell you to do something else.  The rule of thumb in this situation is: follow the most recent instruction.  The person who gave you the second instruction sees that you’re doing something—if they tell you to do something else, you should operate on the belief that they know that what they’re asking you to do is more important.  Someone tells you to do something, and someone else tells you to do the opposite?  It’s likely that something about the situation has changed, and the needs are different now.

Develop a highly refined sense of smell

Think not just about what is allowed, but about what things look like, what they sound like.  Could that tweet be misinterpreted?  You probably shouldn’t send it.  Not sure if it would be a good idea to…  Don’t.

Nothing is about you.  Everything is about the patient.

It can be really easy to suspect that someone doesn’t think that your Spanish is good enough, or that they’re upset with you, or whatever.  Maybe a nurse will walk right by you and ask another interpreter to help them, or you’ll be interpreting for a surgeon, and they’ll ask for another interpreter.  That can be hurtful, obviously.  The thing to keep in mind: don’t take anything personally.  Nothing here is about you, ever.  What the providers want is the best possible care for their patients, and that should be the only thing that you want, too.  Besides, you’re making some assumptions here—with no evidence whatsover.  You’re interpreting this as that nurse doesn’t like me, that surgeon thinks that I don’t speak Spanish well—but, it’s actually a lot more likely that the nurse was thinking about something else and didn’t see you standing there, or that the surgeon was about to ask the patient a question that she knows the patient would be more comfortable answering in front of an interpreter who is older/younger/skinnier/fatter/taller/shorter/maler/femaler than you—you really don’t know until you ask, and if it’s important to you to know, then ask you should.  But, ultimately, the point is that this is not about you—it’s about what the patient needs in that moment, and that is all and everything that matters.

Clarify, clarify, clarify

No one expects you to know what cholelithiasis means.  You’re not sure?  Ask.  No one expects you to know what every single word of Spanish means—you don’t know what every word of English means, right?  So, you’re not sure what a person just said?  Clarify.  People will be glad to know that if you don’t understand something, you’ll ask.  It bears repeating: people will only expect you to know everything if you pretend that you do.

Never answer a patient’s or family member’s question with anything other than…

Never answer a patient’s or family member’s question with anything other than some version of “I’m not a doctor, I don’t know—I’ll go find out.” You can bet that the first time that you think that you know the answer because you have chased down someone to answer the question five times already that day and so you decide to answer it so that you do not bother the doctor or nurse again, this will turn out to be some sort of special case, and you will have made a completely unnecessary mistake—one that could be harmful.

Know your limits in interpretation situations

You will not feel equally comfortable in every clinical area or communicating every kind of message.  If you are much more comfortable with gynecology vocabulary than with anesthesia screening vocabulary: say so.  If you don’t think that you can translate and stay calm when translating for a physician who is going to tell someone that we can’t help their child: say so.  The Surgicorps medical personnel will respect you far more for communicating your limits than they will for trying to take on something that you’re not sure you can do in a way that will be safe for everyone.  Also, if people know that you need help with something, then they can try to give it to you—if they don’t know that you need help, then they won’t try to give it to you.  In general, people like to be helpful.

Know your limits in clinical situations

You may occasionally be asked to help out in an operating room in a pinch.  If you don’t feel competent to help, do not hesitate to say so .  It is far, far less of a problem to say “no” than it is to screw something up.  Peope will forget the one, but you will never forget the other.

Working with your fellow interpreters

Surgicorps brings a finite number of interpreters to Guatemala, and while it sometimes seems as if you are all standing around with nothing to do, it is more often the case that there are not quite enough of us.  Consequently, it is important to try to work together to make sure that all  of the needs of the medical and administrative personnel are covered, and that none of your fellow interpreters is overwhelmed—or starving to death while the rest of us are hanging out in the lunchroom. So, coordinate lunch breaks and the like.  Tell someone if you are leaving for the day—if you disappear and no one knows about it, we not only run short on interpreters sometimes, but someone will be taken out of the game to go look for you and make sure that you are not lying in a bloody heap somewhere.

Another way to help all of us do a better job is to share information about which patients do not speak Spanish well—not all of our patients, or their parents, are fluent in Spanish, and it is important to pass along the word to such patients to the other interpreters.

Surviving the Zombie Apocalypse: The dreaded back door

One of the most helpful things that you can do in Guatemala is to handle the knocks at the back door.  This might sound trivial, but it is also one of the most difficult things to do in Guatemala, and if you find yourself having zombie nightmares while you are here, that back door is probably the reason why.   People show up at the back door for a lot of reasons, ranging from looking for a family member, to dropping off receipts and results of laboratory tests, to showing up for non-surgical treatments like steroid injections or to have a brace made.
You will also go to the back door to call for family members after a surgery, and then translate for the surgeon while they explain how things went.
When people bring forms to the back door, smile, take the form, and give it to one of the local nurses in the pre-op area.

As always, do not answer questions—tell the family members that you are not a doctor, and will go find out whatever it is that they are asking about.
When in doubt about what to do in these situations, remember: you cannot be most helpful by getting tied up trying to solve the problems that appear there.  You can be most helpful by finding, or asking someone free to find, the appropriate person who knows how to deal with the issue, and then making yourself available to interpret.  Most of the time, this will be one of the local nurses.

Some things to think about when you find yourself crying in the bathroom

I presume that you are not a medical professional and do not have much experience with professional-grade compartmentalizing.  Even if you are a professional, if you are human, you are probably going to find yourself crawling off somewhere to cry at some point in your mission.  I can’t deny that life sucks and is unfair, but here are some things that you might think about at these times:

      • We cannot fix everything for everyone, but we can fix a hell of a lot for someone.
      • There are a lot of people who we are not going to be able to help, but every single person that we can help is going to benefit enormously from what Surgicorps does—probably for the rest of their life.
      • As bad as life looks for some of the people that you are going to see, it is infinitely better for a kid with a handicap to be in a place like Obras (the facility where we do our surgeries) than to be lying in the corner of a dirt-floor hut in the jungle somewhere.

No English notes this time, sorry!  Enjoying these posts from Guatemala?  Why not make a small donation to Surgicorps International, the group with which I come here?  You wouldn t believe how much aspirin we can hand out for the cost of a large meal at McDonalds–click here to donate.  Us volunteers pay our own way–all of your donations go to covering the cost of surgical supplies, housing for patients’ families while their loved one is in the hospital, medications, and the like.


Once a year I spend a week in Antigua, Guatemala, where I interpret for a group that does free surgeries for people for whom even the almost-free national health care system is too expensive.  I spend a lot of time in the recovery room. It’s a challenge–you’re interpreting for people who are half-asleep, and often wearing an oxygen mask–and I do like a challenge. (This use of do explained in the English notes below.)  Sometimes the challenges are unexpected ones, though.

One day last year a recovery room nurse asked me to tell a little boy to cough. That’s not unusual in a recovery room–sometimes post-operative secretions in your lungs cause a minor drop in the amount of oxygen that you’re getting, and a cough or two will clear them right up.

Tosa, I said. The kid looked at me uncomprehendingly.  Hmmm, I thought to myself–does the kid not speak Spanish?  That’s not uncommon in Guatemala, where 70% of the population is indigenous and over 20 Mayan languages are spoken.

The father looked at me and smiled. Tosá, he said. The kid coughed. So: no cough when I said tosa, but tosá elicited the desired response.

The father was using a verbal form that’s used in Guatemala and a few other places in Central and South America. Indeed, it’s probably the most distinctive thing about Guatemalan Spanish. However, although I know a few local regional nouns and usually get a happy laugh when I use them, I had never learnt this particular verbal form–Americans would rarely have an occasion to use or to hear it, as it’s used only in the context of particular social relationships, and it wouldn’t be at all typical for a foreigner to have one of those.

My “voseo” lesson at Maximo Nivel, a Spanish language school in Antigua, Guatemala. Picture source: me.

The verbal form in question is called voseo. It’s used in very close relationships–between friends of long duration is the typical one.  In Guatemala, the tu form of verbs is used in many situations in which the usted form would be used anywhere else in the Spanish-speaking world–for example, waiters in restaurants and the ubiquitous vendedores ambulantes (people who stroll constantly through the tourist areas selling stuff, primarily Mayan women of a variety of ethnicities from the surrounding pueblos) will typically address you with the formal terms señor or señora (sir or ma’am)–and then use the tu form of verbs with you, which even on my fifth time in-country sounds weird.

So, you’re wondering: how does one form this mysterious conjugation?  For starters, let’s go over the present indicative.  It’s almost entirely regular, and very easy to relate to the three classes of Spanish verbs.

Spanish verbs end with either -ar, -er, or -ir, with the -ar verbs mostly being homologous with the French -er verbs.  (Sorry–I havent even thought about the others!)  To form the voseo present indicative of almost all verbs, you keep the vowel of the infinitive, add the -s that you would expect in the tu form of the verb, and put the stress on the final syllable.  So:

  • escribir – escribís
  • decir – decís
  • venir – venís
  • tener – tenés
  • comer – comés
  • volver – volvés
  • tomar – tomás
  • buscar – buscás
  • caminar – caminás

Of course, just because Ive learnt the voseo forms doesnt mean that I have anyone with whom to use them–as I said, there are only some relationships in which its OK.  I did use them with the dog at my host familys apartment.  I listened carefully, and they use the formal usted form with him,  but he didnt seem to mind my voseo–although I was sneaking him treats, so who knows…

Enjoying these posts from Guatemala?  Why not make a small donation to Surgicorps International, the group with which I come here?  You wouldn t believe how much aspirin we can hand out for the cost of a large meal at McDonalds–click here to donate.  Us volunteers pay our own way–all of your donations go to covering the cost of surgical supplies, housing for patients’ families while their loved one is in the hospital, medications, and the like.  Scroll down for the English notes, per usual.

English notes

I do like…  This use of do emphasizes something.  As far as I can tell, the primary use, although not the only one, is to emphasize something that is contrary to expectations.  For example, in this Dashiell Hammett quote

I do like a man that tells you right out he’s looking out for himself. Don’t we all? I don’t trust a man that says he’s not. And the man that’s telling the truth when he says he’s not I distrust most of all, because he’s an ass and ass that’s going contrary to the laws of nature.

…you wouldnt expect anyone to like a person who is looking out for himself (a very Trumpian behavior, particularly if youre only looking out for yourself)–hence the do.  How I used it in the post:

It’s a challenge–you’re interpreting for people who are half-asleep, and often wearing an oxygen mask–and I do like a challenge.   Liking a challenge is presumably at least somewhat contrary to expectations–hence, the do.  

In-country: being or taking place in a country that is the focus of activity (such as military operations or scientific research) by the government or citizens of another country (Merriam-Webster)


Um, about that time you almost died…

This is a second attempt at something that I accidentally posted the other day before it was done–sorry!  My laptop died on arrival to Guatemala, and I’m limping along on my cell phone.

Picture source: http://statpsych.blogspot.com/

In science, you often worry about something called the observer effect. This refers to situations in which by observing a behavior, you change it.  It’s a real problem for linguists: tell people that you’re a linguist and you’re there to study how they speak, and you can bet that they’re going to speak differently than they would have otherwise.

One way for a linguist to deal with the observer effect is to get people speaking about something that’s so emotionally engaging that they’ll stop thinking about how they’re speaking. One linguist who worked with teenagers in gangs would ask them to tell him about a really great fight they were in. With people who are not teenaged gang members, you might ask them to tell you about a time that they almost got killed, or the last car wreck that they had seen. You get the picture.

I thought about how linguists handle the observer effect today when my Spanish tutor asked me if I’ve ever seen anyone die.  Once a year I spend a week in Guatemala, where I interpret for a group of surgeons, anesthesiologists, therapists, and nurses who do surgery gratis for people for whom the almost-free national health system is too expensive.  A couple months ago I had a glass of wine with a Mexican friend in Paris. She’s been there for 25 years, and normally we bounce back and forth between French and Spanish as the holes in our vocabularies dictate, et tout s’arrange. This time, though… I tried to switch to Spanish, and it was as if my tongue were frozen–nothing would come out of my mouth. I tried again–bobkes.   (Bobkes explained in the English notes at the end of the post.) I listen to the news in Spanish every day and don’t have any trouble understanding it, but I had to face it: I couldn’t speak Spanish anymore.

No problem, I figured: the town that we go to in Guatemala is jam-packed with schools offering intensive Spanish courses, so I’ll sign up for one. A couple days should loosen up my Spanish-speaking muscles, and all will be well.

Indeed, after a couple of days of 6-hour-a-day private lessons, Spanish is back.  What that means: yesterday my teacher made me explain Zipf’s Law in Spanish, then the principle of compositionality and what the implications of light verbs are for said principle. Today I had to relate–off the top of my head–the history of the migrations of the population of the United States and how they relate to the distribution of anti-Hispanic prejudice, followed by a discussion of regional, generational, social class, and social-contextual variability in language, with examples. (Damn good thing I went to William and Mary.)

So: my professor’s avoid-the-observer-effect technique worked well.  Need a good Spanish school?  Try Maximo Nivel in Antigua, Guatemala.  Want to do something nice for someone who is more than a little necesitado  (needy, in need)?  $20 bucks will pay for more than the entire amount of Motrin (the only painkiller that we can send people home with) that we’ll hand out all week.  Click here to donate, and for today only you’ll also get to see a photo of my adorable fellow interpreter Amelia and a super-cute baby.

Conflict of interest statement: I don’t have one.  Maximo Nivel doesn’t pay me–I payed them for a week of their time, and it was totally worth it.

English notes

bobkes: this word is mostly used on the East Coast, where it means something like nothing, but is stronger than that–perhaps a big fat nothing.  This latter is a very emphatic way of saying nothing.  There are lots of ways to spell it–bopkes, bubkes, bupkes…

Apropos of nothing, here are some babies

How could one possibly know what sounds an infant can hear, and how could one possibly know that they’ve lost the ability to hear the differences between some of them, but not others?  

Differentiating between R and L sounds: American infants and Japanese infants at 6-8 months and at 10-12 months. American English differentiates between the R and L sounds, but Japanese doesn’t. At 6-8 months, the American and Japanese infants do equally well/poorly at telling the difference between R and L sounds. At 10-12 months, the American infants have improved, while the Japanese infants have gotten worse. Picture source: Kuhl et al. (2008), Phonetic learning as a pathway to language: new data and native language magnet theory expanded (NLM-e).
Apropos of nothing but my frustration with my inability to understand the French phrase à propos, here’s a couple of videos on how you do experiments to study how children learn language.  (Linguists use the verb to acquire to describe what you do when you learn your native language(s), which we call language acquisition–hence the title of the second video.)  You’ve probably heard things like this: humans are born capable of hearing the differences between the sounds of all of the languages of the world, but they lose that ability when they start learning their native language.  How could one possibly know what sounds an infant can hear, and how could one possibly know that they’ve lost the ability to hear (the differences between) some of them, but not others?  These videos show you.

I picked these specific videos in part because they’re subtitled, and if you’re not a native speaker of English, they’re great for listening practice.  They have some differences, namely:

  1. The first one, a TED talk by the pioneering child language acquisition researcher Patricia Kuhl, is a presentation by one of the giants of the field.  It has nice graphics, but her language is sometimes much more idiomatic than one might expect, and it might be more difficult for a non-native speaker—or a non-scientist—to understand than the second video.
  2. The second one, from the YouTube channel The Ling Space, features very clear explanations of how the experimental paradigms work, but lacks the great graphics of the Patricia Kuhl TED talk.

Enjoy, and see the English and French notes at the bottom of the post for my best shot at apropos in English and à propos in French.  No guarantees on the French stuff…

Shorter explanation of the experimental paradigms, without the nice graphs of the Patricia Kuhl video, but with very clear explanations.

English notes

Apropos: the dictionary actually doesn’t help much with this.  There are three uses of this that we need to talk about.  One use of apropos in English is as an adjective, in which case it means something like relevant.  Another use of it is in the phrase apropos of, in which case it’s a discourse connector, or a preposition, or something–I’m not entirely sure.  Finally, there’s a special use, apropos of nothing, in which case it’s definitely a discourse connector.  Here are some examples of its use as an adjective meaning relevant or pertinent–all examples but the ones from Twitter are from the enTenTen corpus, via the Sketch Engine web site:

  • The one most apropos in this instance seems to be: to pacify or attempt to pacify an enemy by granting concessions, often at the expense of principle. 
  • Only the cheesiest and best pop song ever! And I found the lyrics to be quite apropos at the time.  
  • It’s tradition to give wood for a fifth wedding anniversary, which is quite apropos for me since I’m married to a blockhead.  (A blockhead is a stupid person, and a block is a particular sort of piece of wood)
  • It is like the modern day holy grail in the face of disruptive tech trends that usurp business models, not to mention Moore’s law being ever more apropos.
  • It might’ve been cool and apropos if blood started coming of the showerhead, but no go. 

Apropos of means something like with respect to, in relation to, as far as … is concerned.  Some examples:

  • I have been thinking about this apropos of the numbers of children claimed to be known to children’s social care.  
  • In 1807 Napoleon wrote Louis, apropos of his domestic relations, a letter which is a good example of scores of others he sent to one and another of his kings and princes about their private affairs.
  • In a letter to Mian Bashir Ahmed, Iqbal has emphasised the point that a comparative study of Ghalib and Bedil apropos of their poetry is necessary.

Now, there’s a particularly common form of this: apropos of nothing.  It is used to indicate that something is not relevant to anything that preceded it, or to introduce something that is not relevant to anything that has preceded it.  The first example explains it about as well as I could:

  • So when you say “ apropos of nothing, person X said this” it means “out of nowhere (relating to nothing) person X said…
  • “Definitely probably,” Wurtzel said, and then asked, apropos of nothing, where I went to school.

…and there’s an especially common use of apropos of nothing, which is straightforwardly a discourse connector used right at the beginning of something that you’re saying.  You use it to introduce a topic that you’re just now introducing and which you’re pointing out is not relevant to anything that’s come before it in the conversation.




…and that’s how I used it in the post.  Why did I use it at all?  I don’t know… I guess because not only is the post not connected to any previous post (other than that it contains a reference–see the first tweet just above–to Trump’s crappy behavior), but there isn’t even any connection between the linguistic thing under discussion (apropos and à propos–this is very meta) and the videos in the post (which are about child language acquisition).  So:

  • Apropos of nothing but my frustration with my inability to understand the French phrase à propos, here’s a couple of videos on how you do experiments to study how children learn language.  

It’s worth noting that this is not what you might call “everyday language”–you would expect any of these uses of apropos in English to come out of the mouth of someone who went to college, is relatively articulate and well-spoken, etc.  This example is a good illustration of that fact:

  • And it’s a weird choice, considering the language Jenna uses (she alternates between swearing and using phrases like “ apropos of nothing”… seriously, what 14-year-old says “apropos of nothing”?), the fact that the boys in her middle school are potheads, and her best friend dresses like a hooker.

Criminy–I’m almost at 1200 words already, and I haven’t gotten to the French à propos at all yet–and WordReference tells me that it’s complicated!  Another time, perhaps–native speakers, please feel free to jump in here…

I am a true American–here’s what that means

I am a true American.  One thing that means: it means that my four grandparents were of four different national origins–and my Russian grandfather came here as a refugee.  (My French grandfather stuck around ’cause he had a cute little student–kisses in Heaven, Grandma.)  My family is Jewish, and Muslim, and Catholic, and Protestant.  Our marriage ceremonies are in English, or Hebrew, or Italian, and we mourn in Aramaic.  My niece speaks English to her mother and myself, but throws tantrums in Mandarin, and if my baby brother and I need to have a discrete discussion about ice cream in her presence, we do it in Spanish.

Another thing that it means when I say that I’m a true American: it means that I spent nine and a half years of my life in the US military.  It means that my cousins were in the service, that my father’s approach to raising me was largely based on what he learned in boot camp, that his cousins were in the service, that my Uncle Leonard’s portrait in his Army uniform still hangs in my cousins’ homes–and that Uncle Leonard’s brother died in the Battle of the Bulge. On French soil, and in the US Army.

Another thing that it means when I say that I’m a true American: I believe in American exceptionalism.  (I believe in French exceptionalism, too, but we can talk about that another time.)  That means that I don’t think you have to “Make America Great Again”–it already is great, and will continue to be so, if our current president doesn’t totally fuck it up, as he is well on the way to doing.

Those are all part of what make me an American.  But, none of them are essential.  Here’s what is the essence of being an American.  Being an American means that in my DNA, you will find an absolute, total, complete commitment to the following:

  • Freedom of speech
  • Freedom of the press
  • Freedom of religion

I say “in my DNA” because it’s not enough to say that I believe in those things.  Belief is changeable.  Freedom of speech, of the press, and of religion are somewhere in my bones, my blood, my soul.  They are what make me an American.

Consequently, I’m offended by the idea of Donald Trump giving speeches on July 4th, the national holiday on which we celebrate our birth as a nation.  For context, please be aware that I don’t offend easily.  For example, although I’m Jewish, anti-Semitism doesn’t bother me in the least–as far as I’m concerned, if you’re not trying to toss my grandmother in a gas chamber, you and I can sit down for a beer and a cigarette, or you can go fuck yourself, as you prefer–your anti-Semitism is not something that I’m going to get offended about (modulo any desires that you might have to kill my grandmother, although in that case, I would not get offended (I hope)–just shoot you).

Nonetheless: Donald Trump standing up in public and pretending to represent my country is offensive.  Why?  Let’s look at the difference between what makes me a real American–and what makes Trump un-American.

Trump select service
Trump’s Selective Service record. Picture source: http://www.politifact.com/punditfact/article/2015/jul/21/was-trump-draft-dodger/

Forget where his parents came from–in America, that’s something that we at least try not to hold against you.  Instead, let’s talk about where his children are going.  More precisely, let’s talk about where they’re not going: they’re not going into the US military.  They’re adults, they’re healthy, and as far as we can tell, they’re mentally intact–but, like their father before them, not one of them has volunteered.  (More precisely, Trump avoided the draft on the claim that he has bad feet, then some decades later claimed that he would be the healthiest president ever.)  The schmuck is happy to send your kids to war, but he’s sure as hell not sending his.

Let’s talk about American exceptionalism–the idea that America is special, and has something to offer the rest of the world.  Here’s Trump’s take on the subject.  Bill O’Reilly, of Fox News–Trump’s most faithful defender amongst the mainstream news media–asked him about his positive remarks about Russian president Vladimir Putin:

“But he’s a killer,” O’Reilly said to Trump.
“There are a lot of killers. You think our country’s so innocent?” Trump replied.
You can watch the video here.
Here’s the thing, though: none of that is of the essence.  What is of the essence is three things:
  • Freedom of speech
  • Freedom of the press
  • Freedom of religion

…and those are the three things against which Trump has most consistently fought.  Advocating changes to the libel laws to make it easier for him to sue people who are critical of him; attacking the press sans répit; and most of all–and, to an American, most horrifyingly–unremittingly advocating prejudice against people because of their religion.  Here’s the thing about Trump’s Muslim ban, his anti-Muslim hate-mongering: The whole récit national of America–our entire national history, creation story, myth, call it what you will–is based on freedom of religion.  If you look at the settlement history of our country, the colonies were all founded by different religious groups who wanted to do their different religious things without being persecuted for it.  Massachusetts was Puritan, Virginia was Anglican, Pennsylvania was Quaker.  And, you know what?  We got along.  There have been exactly zero religious wars in this country–ever.

That’s why you’re seeing Americans all over this country protesting against Trump’s Muslim ban.  A good American is not someone who wears a flag in his lapel (I don’t, and neither do my fellow veteran cousins, or my father, or his cousins; neither did my Uncle Leonard; neither did his brother, who did something that neither Trump nor his children will ever do–he gave his life in our military).  A good American is, in the end, this: someone whose commitment to freedom of speech, freedom of the press, and freedom of religion is absolute; someone who will not give one fucking inch on that commitment for safety, or money, or cheap gas; someone who will defend to the death his enemy’s right to speak, to publish, and to pray as he sees fit.

That’s not Trump.  That’s not his kids.   In the US military, we take an oath.  It’s not an oath to defend the president, or the country, or the government, or a flag.  It’s an oath to protect the Constitution–the place where those freedoms are enshrined.  And by the way–me and the other generations of military veterans in my family?  We vote Democrat.  Happy 4th, and may the true America thrive.